Hospital care at home; early to rise?; probing glaucoma: Upstate Medical University's HealthLink on Air for Sunday, Oct. 6, 2024
Nurse administrator Diane Nanno and Basel Abuzuaiter, MD, discuss the Hospital at Home program. Sleep medicine specialist Ryan Butzko, DO, tells whether rising early is a good idea. Vision researcher Samuel Herberg, PhD, shares his work on glaucoma. And colorectal surgeon Kristina Go, MD, explains how to prepare for a colonoscopy.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," some hospital patients recover in their own homes while they're still technically hospitalized.
Diane Nanno: ... Any physical therapy, occupational therapy, any kind of therapy that's needed in the home are also provided. ...
Host Amber Smith: A sleep medicine specialist answers whether it's healthy to get up early to get a jump on the day.
Ryan Butzko, DO: ... Some people are biologically driven to go to bed early and wake up early, and some people are more biologically driven to go to sleep late and wake up late. ...
Host Amber Smith: And a vision researcher shares his work on glaucoma.
Samuel Herberg, PhD: ... The drainage system that we are interested in is located at an angle that is formed between the iris and the cornea. So these are two tissues that are located in the front part of the eye, and in most of us, this drainage system works just fine. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll explore the benefits and costs of getting up extra early in the morning. Then we will hear about a glaucoma research project. But first, some patients can recover at home even while they remain hospital patients.
Host Amber Smith: From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."
If you've been hospitalized because of illness or injury, and it's going to take some time to recover, how would you like to do that in your home while still under the care of the hospital? Here to explain the Hospital at Home program are Dr. Basel Abuzuaiter, an assistant professor of medicine, and nursing administrator Diane Nanno. They work together overseeing the program at Upstate.
Welcome to "HealthLink on Air," both of you.
Basel Abuzuaiter, MD: Thank you, Amber. Thanks for having us.
Diane Nanno: Amber, thank you for having us.
Host Amber Smith: Ms. Nanno, we spoke with you about this program a few years ago, when it was just getting underway at Upstate. I think at that time it was only for people on Medicare and it was still proving itself. Is that right?
Diane Nanno: That's right. So last we spoke, we were just getting our program off the ground. And just for a reminder: Our Hospital at Home program is a result of a waiver that we applied for and were granted. Within the COVID-19 pandemic, there was a potential for a surge, and we were concerned about our ability to take care of all of the patients that we need to take care of. And so Hospital at Home and the waiver that allows us to take care of inpatients in their own homes, in their own beds, is what we applied for and is what we're talking about today.
So at that time, it was for Medicare patients only. That was who the waiver was granted for, but since that time, we've been able to add patients who are insured by commercial payers as well.
Host Amber Smith: Now, I understand how a program like this would be essential during a pandemic. Does a program like this, in normal times, is it designed to save the patient and the hospital money?
Diane Nanno: Interestingly, we're still feeling the effects of the pandemic, and in many ways that's about staffing, both hospital bed staffing -- although things are much, much better than they were -- but also within the community, post-acute partners where patients go after discharge.
So we really continue to need beds at any one time. We always have patients who are waiting in our emergency departments for acute care beds. So our ability to shift these appropriate patients to acute care in their own homes is a really important capacity strategy for us.
Host Amber Smith: Dr. Abuzuaiter, are there medical benefits to recovering in your own bed?
Basel Abuzuaiter, MD: Yes, Amber. So Hospital at Home is an innovative program that allows admitted patients to continue recovery from the comfort of home, supported by the comprehensive hospital level of care, assisted by their loved ones. Evidence has shown that Hospital at Home patients have better clinical outcomes, fewer hospital readmissions and fewer emergency room visits.
Also, there is nothing like home, right? So patients feel better at home. Being at home reduces the patient's distress. Patients when they are at home, they have lower risks of getting infections. And also it has its own cost effectiveness.
Host Amber Smith: Which type of patient has the most ability to have this option? Because I know not every patient is appropriate for this. But which ones are?
Basel Abuzuaiter, MD: So we have our own selection criteria. So in general, as Diane said, so far, patients who are aged 19 and older, who live within the county, our county, Onondaga County, our patients must be competent. They should be physically able to ambulate, to avoid the risk of falling. Also, we prefer if patients have 24-hour caregiver at home, or at least some support at home.
In the time being most of our patients who we treat at home, we have specific conditions like patients who have lung infections, we call it in pneumonia, who need IV antibiotics, patients who have skin infections, or what we call cellulitis, who also need IV antibiotics to improve, patients who have heart failure and in this condition, they accumulate fluids in their bodies and they need some sort of medications that's given intravenously to get rid of the extra fluids, patients who have chronic lung infection, or inflammation, also known as COPD, who need IV antibiotics. So these are the patients we target so far.
Host Amber Smith: So I was going to ask about which patients might not be candidates. You mentioned they have to be able to walk on their own and kind of get around on their own. Are there other conditions that just really need to be within the walls of the hospital?
Basel Abuzuaiter, MD: Yes. This is a very good question. We have, also, an exclusion criteria. So Hospital at Home targets patients who are acutely sick, meaning they need hospital care, but also they don't need higher level of care, like intensive care unit, where patients need continuous monitoring, they need medications every one hour, they need to be observed by a nurse around the clock. These patients will not be suitable for Hospital at Home.
Again, we exclude patients who need physical support, like patients who are not able to ambulate by themselves. There is risk of fall, despite being at a young age. These patients will not be safe at home, so we prefer to treat them at the hospital. So there is a big list, but this is mainly the things we look at.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Basel Abuzuaiter and Diane Nanno from Upstate's Hospital at Home program.
Ms. Nanno, if a person wants to be involved in this program, but they live in an assisted living facility or a nursing home, is that a disqualifier?
Diane Nanno: Typically, we look at people who live in their own homes and are not cared for by other medical folks.
Nursing home is definitely not appropriate. They certainly can get their care in a different way. Patients who, though, live in independent livings or assisted livings where their nursing care is not provided for them, it would be appropriate. We also look at things like group homes, things like that, because these folks are cared for after discharge, but when they're acutely ill, we can continue to go in because that is their home, just like a private home is someone else's.
And if I could just add a little bit to what Dr. Abuzuaiter said about the patients we look at, it used to be in the Hospital at Home world, we only looked at the types of patients that Dr. Abuzuaiter is talking about. I think Dr. Abuzuaiter would agree that we're able to expand the types of patients that we can take care of based on our capabilities.
So what is it we can do safely at home? And that really opens us up. For instance, we're looking at do we start taking care of surgical patients as well? So it really allows us to take care of a greater number of patients with a host of different clinical conditions.
Host Amber Smith: So let me ask you how medical care is provided when it's remote like this. What can a person who is receiving Hospital at Home services expect?
Diane Nanno: Every patient under the waiver -- remember we're still operating under the waiver -- receives two in-person nursing visits a day at home. Those visits tend to be about an hour each. So if you think about bedside nursing spending two hours at the bedside, there's an incredible amount of education that's done during that time.
In addition to those two nursing visits that are in person, there is a provider visit, and Dr. Abuzuaiter does most of those visits. And that visit can be in person or virtual. We, in our program tend to, see patients on the day of transfer, meaning the day they come from the brick and mortar hospital to their home, and the day of discharge. And then visits in between tend to be virtual unless there's a problem.
Patients get 24-hour monitoring. Patients get transportation from the hospital to their home and then back to the hospital if there's any concern at all, or if there's any kind of diagnostic testing that's needed. Patients get their labs drawn. It comes The specimens come right to theUpstate hospital, and then Dr. Abuzuaiter and his team are able to see the results right in our medical record.
Diane Nanno: Any durable medical equipment that's needed. Typically we look at things like a hospital bed. Does the bed have to be on the first floor? Not necessarily. It really depends on what the patient needs and what is safest for the patient. We tend to order hospital beds for our folks because it's just easier for them.
In addition, any infusions that they need are brought to the home, and the infusions are deliveredby our Nascentia nurses, who are our partners in this. Any physical therapy, occupational therapy, any kind of therapy that's needed in the home are also provided. Medications in addition to those infusions that I mentioned. If there are oral medications, they are set up for the patients, and the patients, actually virtually the nurses watch the patients take their medications.
There's typically a tuck-in visit. So it's although the patient's going to be monitored 24 hours overnight, just kind of making sure that things are going well, there aren't any questions or anticipated concerns from the patients and families. Are pets OK? Absolutely. I'm a dog person. I feel a lot better when my dog's around, and I certainly feel better when my family's around. So that's certainly a positive.
Host Amber Smith: Well, let me ask you, if I can, you've mentioned that there's 24-hour monitoring. Is that done by telephone, or is there a camera? How is that done?
Diane Nanno: Dr. Abuzuaiter, do you want to take that one?
Basel Abuzuaiter, MD: Yes. So we provide patients with a tablet that is connected to the internet through an application where we do the telemedicine visits. This is done every day by an advanced practitioner or by me, and if the patient has any question and would like to contact a provider, we can do that through this tablet.
Diane Nanno: It's like an old-fashioned call button, only high tech.
Host Amber Smith: So, Dr. Abuzuaiter, I'm curious about the doctor-patient relationship or the nurse-patient relationship. Does that change when you have the remote built into this, a little bit?
Basel Abuzuaiter, MD: Yes. All of our patients we have taken care of, they were surprised and happy with this kind of care. Some of them got very emotional when they saw and they practiced and they experienced this kind of care, and they were like, "we did not expect this high level of care at home," and this makes us very happy that we were able to do something and add in the process of healing to the patients.
Host Amber Smith: And we should make it clear. You've talked about patients who are really glad that something like this is available, but no one is forced to do this. If there's somebody who doesn't want to go home, that's perfectly fine, right?
Basel Abuzuaiter, MD: Yes, absolutely. When we do the screening process, we talk to the patient ahead of time. We explain to them about the service, the Hospital at Home service, what are the services we do at home, what they expect, what are the outcomes, and we take their opinion if they are in agreement of going home with the Hospital at Home service, we proceed with the process. Otherwise, we give them the freedom to decide if they want to continue the care at home, at the hospital, or get discharged home.
Host Amber Smith: Ms. Nanno, do you know how many other hospitals across the U.S. are doing a program like this?
Diane Nanno: Three hundred and thirty health systems in our country. Interestingly, Hospital at Home has actually been, they've been doing this in other countries for years and years and years, and we're late to the game. And it's going very well. There are some systems that have been doing this ahead of the waiver, with CMS (Centers for Medicare and Medicaid Services) innovation grants, and those are the systems that really have kind of figured this out.
And the Hospital at Home really is a movement. What's really, really nice about it is, we are able to connect with other systems that are doing this, to help us understand how to better care for our patients within Hospital at Home and care for more patients within it.
A really important population of patients that we care for is end-of-life patients. So, patients who are "comfort care," they're no longer curative. They're bridging to hospice services in our area, aren't necessarily ready for the patient at discharge. So what we do is we bridge those folks to hospice with our comfort care patients with the collaboration of our palliative care team. Sometimes patients pass away before hospice is even able to enroll. We're just so grateful that we're able to get these patients home. And so are they.
Host Amber Smith: Well, thank you both for taking the time to talk about this innovative program.
Diane Nanno: Thank you.
Basel Abuzuaiter, MD: Thank you, Amber.
Host Amber Smith: My guests have been Dr. Basel Abuzuaiter and Diane Nanno. Dr. Abuzuaiter is an assistant professor of medicine, and Ms. Nanno is a nursing administrator, and they work together overseeing the Hospital at Home program at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air.
Should you get a jump on the day by getting up extra early? -- next, on Upstate's "HealthLink on Air."
Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
A trend that has spread on social media lately is the goal of rising at 5 a.m. to get a jump on the day, but is that a good idea? I'm talking with a sleep expert from Upstate to find out. Dr. Ryan Butzko is also an assistant professor of medicine at Upstate.
Host Amber Smith: Welcome back to "HealthLink on Air," Dr. Butzko.
Ryan Butzko, DO: Hi, good morning. Thanks for having me again.
Host Amber Smith: The social media influencers are doing this to be more productive because they feel like they can be more focused at 5 a.m., but is there any evidence that people are more productive before sunrise or the first part of the day?
Ryan Butzko, DO: No. No. There's no specific evidence for that. But this process is called a circadian rhythm, and it's a biologically determined process, which we're all born with. So some people are biologically driven to go to bed early and wake up early, and some people are more biologically driven to go to sleep late and wake up late.
The people driven to wake up early in the morning are probably going to be more productive at 5 a.m. But the people that are biologically driven to go to sleep at, like, 1 to 2 a.m. -- you probably notice: Anyone with teenagers out there have this issue? You try to wake them up at 5 a.m.: What happens? They can't wake up. They are not productive, and they can't do anything until around 10 a.m., when they're naturally designed to wake up.
Host Amber Smith: So if someone is naturally designed to be a night owl type of person, if they're trying to force it and get up at 5, are they going to be ragged all day? Will they fall asleep at night? Will they need naps during the day before they realize that it's just not working?
Ryan Butzko, DO: Yeah, and actually this is one of the more common reasons that people come to see me in the office, especially younger people, in their early 20s or mid-20s, that are just getting out of college and starting a job.
They've been used to their own schedule of choosing what time they want to wake up, choosing their classes, going to sleep late and waking up late, and all of a sudden they're thrust into the workforce, and they have to be up at 6 a.m. to get to a job at 7 a.m.
What happens is they struggle to wake up. Most of the time they're sleeping through their alarms, or when they wake up, they tell me they feel exhausted, and they just can't get through the day, or at least the morning, as productively as they would want. So it's almost like they're waking up in a fog or in, like, a sleep/drunk state, and it takes several cups of coffee for them to finally get into the day.
So usually, what'll happen is they'll wake up, and they won't be productive for about three hours, until they're naturally designed to wake up.
They would only necessarily need naps if they're waking up before they had enough sleep the night before. So if they're still going to bed at about 1 a.m. and trying to wake up at 5 a.m., it's not enough sleep for them, and they'd probably need a one- to two-hour nap during the day just to maintain, in hours of sleep, during the day.
Host Amber Smith: So there's a lot of jobs that start later or that are overnight shifts, but a good portion of office work is still done 8 to 5 or whatever, so people may still have to learn how to get up early, even if they're not a night owl.
Do you have advice for a safe way to do that?
Ryan Butzko, DO: It is. So the circadian rhythm that I talked about, which, again, is our biologically driven rhythm that tells us, it basically gives us, the opportunity to go to bed.
There's two competing forces that allow us to sleep.
One of them is this circadian rhythm, and all that does is give us the opportunity to go to sleep, and usually around nighttime because we are diurnal animals, meaning we are awake during the day and asleep during the night. It allows our body, or gives us the opportunity, to sleep.
The second drive we have is the homeostatic sleep drive, which in a nutshell is the buildup of our sleep drive throughout the day as we're working and doing things.
Once those two things meet at a head, it allows us to fall asleep. This process is, again, inherently biologically driven, so you're genetically predetermined as to what your sleep hours are going to be, but it can be manipulated by behaviors or other external factors.
One of the best external factors to use is sunlight. Sunlight is something that tells our brains that we should be awake because again, we're animals that are normally designed to be up during the day. But it can be manipulated with other behaviors, most commonly eating and exercise.
So when I get people that come to me, I tell them that this can be manipulated by changing your behaviors a little bit, but it has to be done very, very slowly. It's not like one day you're going to sleep at 1 a.m. and waking up at 9 a.m., and then all of a sudden you can just fall asleep at 9 p.m. and wake up at 5 a.m. You have to do tactics that slowly bring your bedtime back, and it has to be done over a period of weeks, otherwise it's just going to get worse.
Host Amber Smith: Well, let me ask you this: If somebody is suddenly put on an overnight shift, does all of what you said apply to them as well? Can they shift and adjust and become used to being a night owl?
Ryan Butzko, DO: It's really, really hard. We actually have a disorder known as shift-work disorder, that we treat, especially because most people are not designed to be up at night. And shift work is usually three to four days a week, so what most people do is, they go in, they do their shifts, and then the other three days that they have, they're on their normal schedule, and it actually wreaks havoc with their body. The best thing that I tell people is that they try to shift it over a couple days before they start to go to work, and they try to stack their shifts consecutively so that they're not shifting back and forth on a daily basis.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ryan Butzko. He's an assistant professor of medicine at Upstate, specializing in sleep medicine.
Now, as long as we get our eight hours, does it matter too much if it's from 11 p.m. to 7 a.m. or 9 p.m. to 5 a.m.? Does that matter, or does it just need to be any eight hours?
Ryan Butzko, DO: It doesn't necessarily matter, but I'm glad you brought up the eight-hour problem because everyone thinks to have a good night's sleep, you have to have eight hours, and it's just not true, actually.
It's true that most people need about seven to eight hours to feel as refreshed and as capable during the day, but some people feel just fine with six hours. And some people feel that they need nine to 10 hours to be able to function at their best. It works as a bell curve, but most people need about seven to eight hours. What we recommend, or what I recommend, is that you need at least six hours of sleep per night, but as long as you're feeling refreshed and OK, the actual amount of time doesn't matter as much.
And does it matter if it's broken up throughout the night or during the day? It's certainly better to get it all done at once because when we sleep at night, we sleep in cycles, and as the night goes on, the cycles get longer, and we have more dream sleep.
And if you're breaking your eight hours of sleep up into, say, four two-hour fragments, the opportunity for you to have dream sleep is a lot less than if you had an uninterrupted night of sleep. So it's definitely better to get it done all during the night, but it's not awful to, say, if you have some shift work, and you have to come back from your shift at, like, 7 a.m., go to bed from 8 to 1, just because you're not able to sleep any more than that, and then try to take a two-hour nap before your shift is something that I usually recommend, so it's not as bad. It can be broken up, but it's certainly better to get uninterrupted sleep throughout one period during the night. Plus, I think most peopleare more comfortable with that type of behavioral pattern.
Host Amber Smith: Do our sleep needs change as we age, where maybe we could get by on six hours, but as we get older, we need more or less?
Ryan Butzko, DO: Yes, actually. As we age, we do have less of a need for sleep, and the effects of sleep deprivation are less pronounced in us as we age. Unfortunately, we also sleep worse as we age. We become lighter sleepers. And that biologically driven clock that I talked about, the circadian rhythm, usually advances, meaning that as we age, we start to feel the need to go to bed earlier and wake up earlier, which is why you start to see those early-bird specials at diners usually populated by our senior citizens.
Host Amber Smith: What about somebody who has a physically demanding job, where they're maybe a construction worker, and they come home physically exhausted, not just tired and sleepy, but physically exhausted. Do they need more sleep, or do they have less trouble falling asleep?
Ryan Butzko, DO: They probably have less trouble falling asleep because of that second process that I talked about building up our sleep drive. If they've been physically demanding the entire day, when the opportunity arises for them to go to sleep, it's going to be much easier for them to go to sleep.
So with people that are struggling with falling asleep at night, especially falling asleep and not necessarily staying asleep, what I tell them is to be active. Don't be sedentary, because the more active that you are and the more that you stimulate both your mind and body during the day, it's going to give you an easier opportunity to fall asleep at night.
Do they necessarily need more sleep? No. They don't necessarily need more sleep.
Host Amber Smith: What about someone who has a habit of watching television or scrolling on their phone before they go to bed? Do you see that as an issue very often?
Ryan Butzko, DO: Almost always. (laughs) That's one of the core components of sleep hygiene. So when I did talk about the effects on our drive to fall asleep: Light keeps us up. So the light from the TV screen and the light from the phone, especially blue light, is something that tells our brain that, no, I'm not quite ready to fall asleep. It's not time yet. This is kind of a small process.
What I see is more of an issue is people are scrolling through their social media or watching an engaging television program, and they're not allowing their brain the opportunity to shut down. And while they're still engaged and active, it becomes very, very hard to fall asleep. So usually what I recommend: not watch TV, not use your phone, especially in the bedroom. If you want to do it outside the bedroom and try a less engaging television program, or maybe a game that helps put you in a relaxed state, that's fine, but once you get to the bedroom, it's just for sleep.
Host Amber Smith: If someone came to you with a complaint of having trouble focusing and also struggling to get a good night's sleep, what are the things that you, as a provider, would be potentially concerned about?
Ryan Butzko, DO: Well, almost always, one of the first things we think about is sleep apnea. So if you have the typical characteristics of sleep apnea, I'll usually send you for a sleep study. But if you don't, then I'll start asking about your behavioral patterns and your family's behavioral patterns, because, like I said, the circadian rhythm is a biological process, but it's genetically driven.
So what I tend to see is families that are night owls are just that: families that are night owls, and most of their family also likes to stay up late and wake up late the next morning. If I can nail down their sleep habits and what they would like, I can use some medications and, actually, timely light therapy to help to manipulate the circadian rhythm, to try to get it to what they desire their sleep hours to be.
Most importantly, this is not an easy process. Like I said, it takes weeks to do, and once you have your desired sleep hours, you have to be consistent because you're kind of fighting your own biology. And while you can make it work while you are consistent with the sleep hours, it is incredibly easy to fall back into the old habits if you're not consistent with it.
Host Amber Smith: So an early bird that is born into a family of night owls is up for kind of a rough run.
Ryan Butzko, DO: Yeah, usually they are.
Host Amber Smith: Now, in terms of focusing, do you ever recommend caffeine products? There's a lot of beverages that have caffeine and products that you can eat that have caffeine. Do those really help someone focus if they haven't been able to sleep well?
Ryan Butzko, DO: Caffeine's an interesting drug, and as a coffee drinker myself, it's hard for me to speak against caffeine. The drug works as a blocker to one of the receptors in our brain that is one of our sleep receptors, essentially. So by drinking coffee, you're blocking the body's perception of sleep.
I don't usually recommend commercial caffeine products, mostly because a lot of the energy drinks that we see are not just caffeine. There are a lot of other chemicals in those products that aren't necessarily just caffeine. And they're not all tested, and we don't know how safe they are. And I have had, very rarely, some patients have some heart issues associated with that.
But a timely cup of coffee can really work to your advantage, especially if you're working on shift work, as long as you don't overdo it. Everything in moderation.
Host Amber Smith: Dr. Butzko, I really appreciate you making time for this interview. Thank you.
Ryan Butzko, DO: Of course. Thank you for having me.
Host Amber Smith: My guest has been Dr. Ryan Butzko, a sleep specialist who is also an assistant professor of medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," the questions about glaucoma that vision researchers are trying to answer.
From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."
An Upstate researcher from the Center for Vision Research won a grant recently that will hopefully help lead to better understanding of glaucoma. Here to discuss his work is Dr. Samuel Herberg. He's an assistant professor of ophthalmology and visual sciences.
Welcome to "HealthLink on Air," Dr. Herberg.
Samuel Herberg, PhD: Thank you very much. Good morning, everyone.
Host Amber Smith: Now I understand your grant is from the National Eye Institute, and it's to help build something. Can you explain what you're making?
Samuel Herberg, PhD: Yes, that is correct. The grant we received is an R-21 grant, which is a two-year grant. And the purpose of this project is to build a device that will enable us to study the biology of a tissue that is important in normal pressure regulation. But if this tissue becomes impaired, it does play a role in glaucoma.
Host Amber Smith: So is this model that you're making, is it going to look like, will it be like a physical eye, or is it a model, like a computer model?
Samuel Herberg, PhD: It is a physical model, but not of the entire eye. The tissues that we are interested in are really small.The trabecular meshwork and the Schlemm's canal, these are the two principle tissues we are interested in. They're located in the front of the eye, and they're really, really small. So for the purpose of the modeling, we focus on the tissues that we are trying to understand better, and we re-create a version of the tissue in vitro (test tube experiments) so that we can do experiments in the laboratory.
Host Amber Smith: I see. Now, before we get too far into this, I feel like we ought to describe glaucoma. Can you tell us how many people are affected by glaucoma?
Samuel Herberg, PhD: This is a disease group. It's not one particular disease. It's really more of a group of diseases. Currently the number is approximately 80 million patients suffering from a version of glaucoma worldwide. And the predominant cases of this disease are characterized by high pressure in the eye. So there are other versions or other manifestations of the disease, but the majority of all glaucoma patients are being treated for high pressure.
Host Amber Smith: Is the high pressure, does that cause pain in the eye?
Samuel Herberg, PhD: Surprisingly not. There're very few manifestations that you could physically feel as a patient, and that is part of the problem with the disease. It has very few symptoms, and if that makes the diagnosis relatively difficult to diagnose. And also, treating later on is somewhat challenging if the patient is not being seen by a provider.
Host Amber Smith: Is this the kind of thing if you go for an annual eye exam, would they be able to detect it?
Samuel Herberg, PhD: Absolutely. This is exactly what's being done clinically, by an optometrist or an ophthalmologist at the office as a routine part of the exam, the pressure is measured within the eye. And if there's any indication that the pressure for any given patient is outside of what is considered normal, then there would be follow-up examinations looking more closely if there are, in fact, any sos of evidencees for disease.
Host Amber Smith: So if it is diagnosed, and they think that the person has glaucoma, is there a way to treat it?
Samuel Herberg, PhD: Yes, there are treatments available. It is important to note up front that as of right now, there is no cure. The disease can be managed clinically, and this is exactly what we are doing. However, there's no cure.
Part of the reason is, that it is really a multifactorial disease. It's not a single cause. It's probably more of a group of causes. And they're likely dynamically affecting each other. So as of right now, we do not know what causes the disease. High pressure that I mentioned a little bit earlier is considered a risk factor. So if a patient presents with elevated intraocular pressure, the attending physician or the care team is then making arrangements to lower the pressure in the patient's eye.
That does not necessarily mean there is optic nerve damage. So the nerve that transmits the visual inflammation to the brain so that we can perceive our environment is really what is being damaged in the disease. So it's a neurological disease, a neuropathy. So if that occurs, the patient would lose vision irreversibly. So that's why lowering pressure is the first line of treatment, although the patient may or may not already have symptoms of impaired vision.
Host Amber Smith: So researchers haven't figured out what causes this. Are there other major pieces of the glaucoma puzzle that still need to be discovered?
Samuel Herberg, PhD: Yes, there are a list of sort of well-known and relatively well-understood risk factors. Some of them are unchangeable. We cannot change a person's age, sex or race. There are also a few changeable, potentially changeable, risk factors such as the diet, the environment that the patient is in, and ultimately pressure as one of the most important risk factors that can be treated if it elevates in the eye.
Host Amber Smith: The risk factors you mentioned -- race, gender, age which ones are more at risk?
Samuel Herberg, PhD: That's a very good question. So age is probably one of the stronger correlative readouts for developing the disease. But there's also a good amount of literature on race. African-American populations are at a higher risk for developing the disease.
But this is really not something that I particularly study in my laboratory. I am, as I mentioned earlier, I'm not a clinician. I do not see or treat patients. So we read the literature, and we take in the information. But that is not something we address in the laboratory.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Samuel Herberg. He's an assistant professor of ophthalmology and visual sciences, and he's doing research that hopefully will help us understand glaucoma.
So getting into your project, can you explain the drainage system of the eye?
Samuel Herberg, PhD: Yes, the drainage system that we are interested in is located at an angle that is formed between the iris and the cornea. So these are two tissues that are located in the front part of the eye, and in most of us, this drainage system works just fine. However, in patients that have underlying conditions that are not fully worked out, the outflow pathway might become impaired. What that means is that the tissues that are responsible for filtering the fluids outside of the eye to maintain a balance between production of fluid and drainage of fluid. If that tissue becomes impaired, there would be an imbalance of fluid maintenance within the eye, raising the pressure over time, and that tissue responsible for doing this is located in that angle.
The principle components are the trabecular meshwork, which is sort of a fenestrated (multi-opening) filtering type tissue with various layers. And the biology of that is complex in itself. And then immediately adjacent to this tissue is an endothelial vessel, a little bit like a blood vessel, but it is a more of a lymphatic vessel, so it does not contain blood. The fluid that comes from the underlying trabecular meshwork is then being filtered into the lumen (cavity) of this vessel, and from there it exits the eye into the venous circulation.
So it's really a two-component tissue, let's say. But there's other parts of the outflow tract that can be dysfunctional. In my laboratory, we really focus on the conventional outflow pathway. The majority of fluid goes through this tissue, and therefore a lot of my colleagues and myself included focus on the trabecular meshwork and the Schlemm's canal.
Host Amber Smith: When we're talking about a drainage system in the eye, the only thing I think of is tears. But that's not what you're talking about.
Samuel Herberg, PhD: That is correct. So this would be an intraocular, so within the eye. So you can think of the eye like a fluid-filled pressure vessel. There's continuous fluid production from tissues within the eye, and that fluid needs to exit to maintain a normal homeostatic level of intraocular pressure, pressure that is responsible for maintaining visual acuity and that we can perceive the outside world in an unobstructed manner. So this is fluid that is being produced from inside the eye and is then shuttled outside of the eye.
Host Amber Smith: So this fluid keeps the tissues moist, it sounds like?
Samuel Herberg, PhD: It keeps them nourished. Several of these tissues that are located in the front of the eye are avascular, so there's no blood supply to certain parts of this, which is important to maintain clear tissues, that the light can enter the eye in an unobstructed way.
Imagine if we had blood vessels spanning the front part of your eye. Light would not be able to enter the eye in the correct manner and then be focused using your lens onto your retina, which is the tissue responsible for carrying this information forward into the brain using the optic nerve.
So the tissues are avascular, and thus the fluid is partially nourishing these avascular tissues. It contains various nutrients but also contains byproducts of cellular turnover. And these waste products need to exit the eye. And this is also part of the responsibility of this fluid.
Host Amber Smith: So with the research you're doing, does the drainage system of the eye malfunction and cause high pressure, or does the buildup of high pressure cause the drainage function to malfunction?
Samuel Herberg, PhD: Probably both. It is very difficult to identify the onset because patients who suffer from the disease do not present with major symptoms until a significant loss of vision. So there's no pain associated with developing outflow problems. And then for researchers like myself in the laboratory, we rely on cellular material that we can explant from donor eyes, so patients or normal individuals who have passed away and donated their eyes for research purposes. These are the sources for our cellular materials. So we get the cells, and then we can study them in a controlled environment in the lab.
What we cannot control at any given experiment is if this patient had normal or high pressure, and if that was a result of dysfunction, and if this was amplified by the high pressure. So the general consensus is that it is very likely that the tissue itself becomes impaired. And then as a result of this, the pressure rises, and that will likely have some feedback information in exacerbating the dysfunction, so to speak.
Host Amber Smith: Who are your collaborators, and what are their roles?
Samuel Herberg, PhD: So for this project, I have two main collaborators on board. One is a colleague from Syracuse University. His name is Dr. Pranav Soman, in biomedical and chemical engineering, and we've been working together for a while. His expertise is really on biofabrication, using high-end techniques and state-of-the-art manufacturing to build devices.
And the device we are using is really made in his laboratory. It's called a microfluidics chip, a little platform, you can imagine, almost like a little bioreactor that we can fill with human cell material. And then we can study the response of the cells to fluid flow that we can simulate using small tubing and controlled fluid pumps so that we can simulate the normal aqueous humor outflow.
And to validate this new model that we are attempting to establish with this grant,the model to use to balance or validate it against is a model developed in a collaborative lab at Indiana University School of Medicine, Dr. Weiming Mao. And he has agreed for us to come and see the apparatus necessary to build this. And then we can relatively easily set this up in my laboratory to have a tissuemodel system that we can sort of benchmark our new completely bio-engineered system against to determine if the values we obtain are comparable to in vivo, or tissue-level, measurements, and ultimately enhance the physiological relevance of these bioengineered tissues.
Host Amber Smith: So you said this is a two year grant. If everything went perfectly, what would you hope to have accomplished after two years? What do you think might be practical?
Samuel Herberg, PhD: This is a tough question because a lot of times when we write these grant proposals, especially for a two-year mechanism, The NIH (National Institutes of Health), and the National Eye Institute in particular, they're interested in funding quote, unquote "high risk, high reward" projects. So this is a mechanism for which projects receive funding that are really trying to push the envelope with a greater risk of failure. However, if we are successful in executing our goals, we should be able to really generate a new model system that would facilitate mechanistic studies of cell biology. And that can then also be done outside of my lab. This can be transferred to other laboratories if they're interested in setting this up themselves. And this is an area that we are interested in helping others as well.
Host Amber Smith: Well, Dr. Herberg, I appreciate you taking us into your lab and telling us about your work. Thank you.
Samuel Herberg, PhD: Thank you very much.
Host Amber Smith: My guest has been Dr. Samuel Herberg, an assistant professor of ophthalmology and visual sciences at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from colorectal surgeon Dr. Kristina Go from Upstate Medical University.
How should someone prepare for a colonoscopy?
Kristina Go, MD: What I tell my patients is, in the week leading to your colonoscopy, to avoid foods that are high in fiber or high residues, such as leafy green vegetables. (Remember to return to that after your colonoscopy, of course.)
The whole purpose of a bowel prep is to completely clean out your colon, which, in no euphemistic terms, it's really just having a lot of severe diarrhea for the day before, while you're drinking your prep. In terms of trying to tolerate this amount of liquid that you're having to drink, I give patients some pointers. Some of them work better than others. Placing your prep on ice or drinking it through a straw can sometimes decrease how unpalatable the flavor of the prep is. Sucking on lemon slices or sugar-free menthol candy drops can also decrease that feeling of nausea.
The day before your colonoscopy, make sure to drink lots of clear liquids in addition to your bowel prep. A patient needs to drink clear liquids, as in nothing that is opaque, nothing with any kind of solid components to it, for the entire day before the day of their colonoscopy. Drinking water or fluids keeps you hydrated and can also decrease the symptoms of nausea that can be associated with this type of prep.
And on the day of your colonoscopy, take a deep breath in and out. It's a relatively painless procedure. And after you're done, you can go back to the regular diet.
Host Amber Smith: You've been listening to colorectal surgeon Dr. Kristina Go, from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Nancy Cherico is a retired psychologist who says the healing power of poetry has sustained her through the sudden death of an adult child and through years of caregiving for her husband, who had Alzheimer's. Her short, eloquent poem reflects that healing.
"A Widow Gives Away Her Husband's Clothes"
Although she saw him wear his red suspenders only once,
her hands balk at putting them in the plastic bag.
His baseball caps are not so problematic. She knows
his favorites -- Red Sox, Sardinia, the one with the Cuban
revolution star. It is easy to bestow them on daughters, sons.
She thought he had too many socks, but when she counts them
she regrets this unspoken criticism -- hers outnumber his.
To atone, she reduces her own supply. His smell is gone
from the closet now, but his shoes keep the shape
of his feet, ghosts holding voids. These are only things,
she says to herself as she kisses the place
on his blue checked shirt over where
his heart used to beat.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
Next week on "HealthLink on Air," what to do about test anxiety.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.